Statement Of Service Form printable pdf download

Statement Of Service Form

Statement of Service

Instructions: Documents filed with the Commission must also be served on each of the other parties to

the case. Service may be made by hand delivery, registered, certified or regular mail, private delivery

service, leaving a copy at the principal office or place of business of the person required to be served, by

email, or by fax. A statement of service must indicate: (1) the type of document served; (2) the party on

which the document was served; (3) the date of service; (4) the street address, email address, and/or fax

number at which service was made; (5) the method of service; (6) the name of the person who served

the document; and (7) the signature of the person who served the document. If service is by email,

you must provide the email address. If service is by fax, you must provide the fax number.

Below are two forms, which may be used to provide a statement of service. Below each form is a

completed sample. You may use either form or create your own, as long as your statement of

service includes all of the information required in the instructions in the paragraph above.

Version 1

Statement of Service

On (date) _______________, I served (type of document)

on (party

served) __________________________ by:

(Check the appropriate box(s) and write in the street address, email address, and/or fax number at

which service was completed.)

☐ Hand delivery at ____________________

☐ Registered, certified, or regular mail to____________________________________

☐ Private delivery service to______________________________________________

☐ Email to ______________________

☐ Fax to_____________________________

Signature

Date

Print Name

Page 1 of 3

Statement Of Service Form